Full Implementation of Depression Screening in Primary Care Reduces Disparities, Improves Recognition for All Patients

Routine depression screening in the primary care setting lowered screening disparities and increased recognition of symptoms for groups at risk of undertreatment, including racial and ethnic minority individuals and patients of older age.

Full implementation of depression screening is associated with a substantial increase in screening rates among groups at risk for undertreatment of depression, according to study recently published in JAMA Network Open.

Depression screening disparities also narrowed over time after full implementation, suggesting that routine depression screening in primary care may reduce screening disparities and improve recognition and appropriate treatment of depression for all patients.

Though primary care is often a gateway to treatment, depression often goes unrecognized in individuals presenting with depressive symptoms in the primary care setting. Under-recognition of presenting symptoms occurs more frequently among men, racial and ethnic minority individuals, people with language barriers, older adults, and patients with public insurance. These populations are less likely to receive adequate care, according to the study.

Whether general depression screening in clinical practice is associated with equitable screening for all population groups remains uncertain. Researchers conducted a cohort study to examine depression screening rates among populations at risk for undertreatment of depression during and after rollout of general screening.

They examined electronic health record (EHR) data from 52,944 adult patients at 6 University of California, San Francisco, primary care facilities from September 1, 2017, to December 31, 2019. Depression screening rates were assessed after implementation of a general screening policy.

Researchers identified 52,944 unique, eligible patients with 1 or more visit in 1 of the 6 primary care practices during the entire study period. Depression screening was found to have increased from 40.5% at rollout in 2017 to 88.8% in 2019.

In 2018, the likelihood of being screened decreased with increasing age (adjusted odds ratio [aOR], 0.89 [95% CI, 0.82-0.98] for ages 45-54 and aOR, 0.75 [95% CI, 0.65-0.85] for ages 75 and older compared with ages 18-30). Additionally, patients with limited English proficiency, except for Spanish-speaking patients, were less likely to be screened for depression than English-speaking White patients (Chinese language preference: aOR, 0.59 [95% CI, 0.51-0.67]; other non–English language preference: aOR, 0.55 [95% CI, 0.47-0.64]).

Depression screening had increased dramatically for all at-risk groups by 2019, and disparities had disappeared for most groups. In 2019, odds of screening were only still significantly lower for men compared with women (aOR, 0.87 [95% CI, 0.81 to 0.93]).

Overall, full implementation of depression screening was associated with a substantial increase in screening rates among groups at risk for undertreatment of depression and the narrowing of depression screening disparities.

These findings suggest that routine depression screening in primary care may reduce screening disparities, improve recognition of depression, and improve appropriate treatment of depression for all patients, according to the investigators. However, it is unclear whether improving equity in depression screening will translate into equal benefit from depression care.

The authors suggest future evaluations to determine whether screening is associated with appropriate diagnosis, initial treatment, adequate follow-up, and remission.

The study has some limitations. The use of an EHR-based data set may have limited the accuracy of race and ethnicity and preferred language data.

Additionally, although gender minority groups disproportionately suffer from depression and its undertreatment, researchers were unable to assess screening rates among individuals in these groups because more inclusive gender identity data were not collected until 2019.

Reference

Garcia M E, Hinton L, Neuhaus J, Feldman M, Livaudais-Toman J, Karliner L S. Equitability of depression screening after implementation of general adult screening in primary care. JAMA Netw Open. 2022;5(8):e2227658. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2795293. Published August 18, 2022. Accessed August 19, 2022.